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Whistleblower Gets Large Health System Dinged Half a Million for Overbilling

Analysis  |  By Amanda Norris  
   May 18, 2023

Yale New Haven Health and Northeast Medical Group have agreed to a hefty settlement for allegedly submitting false claims to Medicare and Medicaid.

The federal and state governments allege that the Yale New Haven Health and Northeast Medical Group submitted false Medicare and Medicaid claims, which has since resulted in a hefty settlement from the system.

The settlement agreement totaling $560,718 should resolve allegations of overbilling by Yale, violating federal and state laws for submitting false claims to Medicare and Medicaid for services billed by physicians when they should’ve been billed at the lower reimbursement rate of mid-level providers, according to the Department of Justice (DOJ).

The DOJ says the healthcare providers submitted the false claims between July 2014 and June 2020, and as a result, the providers improperly received between 10% and 15% more in Medicare and Medicaid reimbursements for the allegedly falsely billed services.

The allegations were initially brought in a lawsuit filed by a whistleblower, a former employee of Northeast Medical doctors’ group. According to the DOJ, the whistleblower will receive about $106,500 as her share of the settlement.

Yale New Haven Health and Northeast Medical deny the allegations but agreed to the settlement to avoid a protracted legal process, according to the settlement.

A situation like this is worst-case scenario for revenue cycle leaders, and leaders should ensure their organization’s billing practices are appropriate. Address any errors identified as soon as possible and remember to return overpayments and provide education to your staff as soon as errors are discovered.

One way to easily keep an eye on fraudulent billing practices is through an internal audit. If an internal audit determines that Medicare was billed inappropriately, your orginization is in potential violation of the False Claims Act.

Revenue cycle leaders should ensure all their teams—everyone from coders to providers—understand the financial penalties associated with False Claim Act violations and be familiar with all other compliance penalties.

Amanda Norris is the Associate Content Manager of Finance, Payer, Revenue Cycle, and Strategy for HealthLeaders.


KEY TAKEAWAYS

The providers at the health system allegedly improperly received between 10% and 15% more in Medicare and Medicaid reimbursements for falsely billed services.

The settlement agreement totaling $560,718 should resolve allegations of overbilling.

A situation like this is worst-case scenario for revenue cycle leaders, and leaders should ensure their organization’s billing practices are appropriate; one way to do so is through internal audits.


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